MKSAP Quiz: Screening after prostate cancer diagnosis
A 65-year-old man is evaluated after being diagnosed with high-risk prostate cancer. He is asymptomatic. Transrectal ultrasound biopsy showed multiple foci of prostate cancer in both lobes with the highest Gleason score of 8. Following a physical exam, tests, and treatment, what is the most appropriate screening test to perform next?
A 65-year-old man is evaluated after being diagnosed with high-risk prostate cancer. He is asymptomatic. Transrectal ultrasound biopsy showed multiple foci of prostate cancer in both lobes with the highest Gleason score of 8.
On physical examination, vital signs and the remainder of the examination are normal.
CT and bone scan are negative for metastatic disease.
The patient has been started on treatment with androgen deprivation therapy plus radiation therapy.
Which of the following is the most appropriate screening test to perform next?
A. Dementia screening
B. Doppler ultrasonography of the lower extremities
C. Dual-energy x-ray absorptiometry scan
D. Exercise stress test
MKSAP Answer and Critique
The correct answer is C. Dual-energy x-ray absorptiometry scan. This content is available to MKSAP 19 subscribers as Question 23 in the Oncology section. More information about MKSAP is available online.
The most appropriate screening test to perform next for this patient is a dual-energy x-ray absorptiometry (DEXA) scan (Option C) to establish baseline bone density and to assess for fracture risk. Patients diagnosed with high-risk nonmetastatic prostate cancer are usually treated with a combination of androgen deprivation therapy (ADT) and radiation therapy, which has been shown to improve survival. ADT results in many short- and long-term adverse effects. Short-term effects include loss of lean body mass, fatigue, gynecomastia, hair loss, decreased libido, erectile dysfunction, and vasomotor symptoms. Long-term risks include a possible increase in cardiovascular disease and cognitive dysfunction, increased risk of venous thromboembolism, and reduction in bone density. Patients with nonmetastatic cancer with one or more risk factors for osteoporotic fracture should be offered DEXA screening. ADT is a risk factor for osteoporosis. Patients who are prescribed a drug that causes bone loss or whose bone mineral density is near the threshold of treatment should be screened every 2 years. For patients with osteoporosis, bisphosphonates or denosumab may be offered to reduce the risk of fracture.
There is increasing but inconsistent evidence that ADT is associated with cognitive impairment and Alzheimer disease. However, there is no recommendation for routine dementia screening (Option A) in patients taking ATD, and the U.S. Preventive Services Task Force has concluded that there is insufficient evidence for or against routine dementia screening in older adults.
Patients treated with ADT may be at risk for cardiovascular disease and are at increased risk for venous thromboembolism. However, there are no recommendations for screening with either exercise electrocardiography (Option D) or Doppler ultrasonography (Option B) in asymptomatic patients.
Key Points
- Patients with nonmetastatic cancer with one or more risk factors for osteoporotic fracture should be offered dual-energy x-ray absorptiometry screening.
- Patients with nonmetastatic cancer who are prescribed a drug that causes bone loss or whose bone mineral density is near the threshold of treatment should be screened every 2 years.